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The importance of an Alternative Life Safety Measures policy

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January 1, 2018

Editor's note: In this excerpt from the new HCPro book Analyzing the Hospital Life Safety Survey, Third Edition, author Brad Keyes, CHSP, explains how an Alternative Life Safety Measures policy can help you maintain compliance with the Life Safety Code®. Visit http://hcmarketplace.com/analyzing-the-hospital-life-safety-survey for more information.

The expectation of The Joint Commission, the Centers for Medicare & Medicaid Services (CMS), and all of the other authorities having jurisdiction (AHJ) is that your healthcare organization will be fully compliant with the Life Safety Code® (LSC) at all times. This means every door that is required to close and latch does so, every fire-rated or smoke-resistant wall is free of unsealed ­penetrations, and every exit access corridor is clear of obstructions. The LSC does not permit you to operate a facility knowing that you have unresolved or unaddressed life safety deficiencies. There is a good reason for this expectation of full compliance: Without it, people die.

Over the years, fatal fires have occurred in healthcare organizations, as well as other types of occupancies, that later were determined to have serious LSC violations. Many of these fires occurred during construction, renovation, or other types of repairs. Construction is part of nearly every healthcare organization’s existence, and it is only logical that, in order to make building improvements, certain features of life safety have to be impaired—for example, shutting down the sprinkler system to install a new branch of piping, or blocking access to a stairwell to create a new access to an addition. The old adage “You can’t make an omelet without breaking an egg” comes to mind.

Combine this necessary interruption of safety features with the need to continue to operate and occupy the building, and you have a recipe for a potential disaster. The LSC recognizes this potential and includes a couple of paragraphs that say, in part:

No building, new or existing construction, is permitted to be occupied in any form if the building has violations with the provisions of the LSC, unless all of the following conditions apply:
--- A plan of correction has been approved by the AHJ
--- The occupancy classification remains the same
--- No serious life safety hazard exists as determined by the AHJ

And:

Buildings are permitted to be occupied during renovation, repair or additions only when the required means of egress and the required features of fire protection are in place and continuously maintained for the areas that are occupied, or where alternative life safety measures that are acceptable to the AHJ are in place.

These two sections of the LSC permit an existing building that is under renovation or repair to remain occupied, provided alternative measures are implemented that are acceptable to the AHJ. However, as we will learn later on in this text the typical healthcare organization has multiple AHJs, so the chance of all of them agreeing on one single plan can be slim—what the local fire marshal approves might not be acceptable to the state department of health, for example. So, a plan must be developed, one that is acceptable to most if not all AHJs, that evaluates all hazards and potential risks whenever any feature of life safety is impaired for any reason. The accreditation organization (AO) have developed such a plan, and it’s called the Alternative Life Safety Measures (ALSM) policy. The Joint Commission has the same requirement, although they refer to their program as the Interim Life Safety Measure (ILSM) policy.

ALSM Policy
Every organization that is accredited by The Joint Commission (TJC), the Healthcare Facilities Accreditation Program (HFAP), Det Norske Veritas, GL (DNV), or Center for Improvement in Healthcare Quality (CIHQ) is required to develop a policy that protects occupants during periods when the LSC is not met, such as during renovation, maintenance, and repair work. The AOs do not dictate what the policy must say, but they do provide specific requirements that must be addressed, which are:
--- The policy must identify when a particular compensating measure is required to be implemented and to what extent that measure is implemented.
--- Whenever the fire alarm system is fully or partially out of service for more than four hours in a 24-hour period, the healthcare organization must notify the local fire department and initiate a fire watch
--- Whenever the sprinkler system is fully or partially out of service for more than ten hours in a 24-hour period, the healthcare organization must notify the local fire department and initiate a fire watch
--- If an exit is fully or partially obstructed, the healthcare organization must post signage that identifies alternative exits by location to everyone affected by the obstruction

In addition to the above, the ALSM policy must incorporate special alternative measures to be followed when deficiencies to a feature of life safety cannot be immediately corrected, such as during construction. These alternative measures must consider the following:
--- On a daily basis, the healthcare organization inspects exits that are affected
--- The healthcare organization provides temporary but equivalent operable fire alarm detection systems when a fire alarm system is impaired
--- The healthcare organization provides additional firefighting equipment
--- The healthcare organization provides temporary construction barriers that are smoke-tight or made of noncombustible or limited-combustible materials that would not contribute to the spread of a fire
--- The healthcare organization increases surveillance of construction areas, areas used for staging of construction materials, excavation and field offices
--- The healthcare organization enforces the practice of removing construction debris, using storage, and performing basic housekeeping duties to reduce the combustible load inside the building as much as possible
--- The healthcare organization provides additional training on the use of firefighting equipment for those who would be expected to use it
--- The healthcare organization conducts an additional fire drill per shift per quarter in all areas affected by the deficiency
--- On a monthly basis, the healthcare organization tests and inspects temporary systems
--- The healthcare organization provides additional education to building occupants that promotes awareness of the life safety deficiencies, construction hazards, and any temporary or alternative measures that have been implemented to maintain fire safety
--- The healthcare organization conducts training for building occupants who are affected by the life safety deficiencies

Not all of the above measures have to be implemented each time an assessment is made. The AOs say the healthcare organization (not the AHJ) is the entity that decides when and to what extent these measures are implemented, if at all. However, a surveyor can still cite you for inadequate ALSMs if he or she disagrees with your decisions, so it is important to take a conservative approach to your ALSM assessments.

In addition, the AO standards often requires your ALSM policy to have written criteria explaining when and to what extent each measure is implemented. It may seem daunting to identify in writing all of the possible situations where you may have to implement each ALSM. Fortunately, this has already been accomplished for us in the form of a spreadsheet matrix, created by other individuals in the industry and posted on numerous listservs for public use. Each Life Safety deficiency must be assessed for ALSMs the same day that you discover the deficiency. If you cannot resolve the deficiency before you leave the facility for the day, then an ALSM assessment needs to be made.

ALSM policy elements
Now, let’s take a closer look at each element of the ALSM policy.

Whenever the fire alarm system is fully or partially out of service for more than four hours in a 24-hour period, and whenever the sprinkler system is fully or partially out of service for more than 10 hours in a 24-hour period, the healthcare organization must notify the local fire department and initiate a fire watch.

One of the biggest problems in complying with this measure is determining when the fire alarm or sprinkler system is “out of service” to the point that the local fire department needs to know. If a single smoke detector is taken out of service for construction in a small area, that doesn’t seem to meet the concept of a “system.” However, if an entire branch circuit is disabled, that seems more in line with the “system” description. The “four hours in a 24-hour period” clause was changed from the phrase “more than four hours” when it was discovered that some unscrupulous individuals would put their system back in service every three hours and 55 minutes to avoid having to contact the local fire department. The easiest way to notify the local fire department of this outage and still retain documentation that you did so is to send a fax, which can provide you with a date and timestamp.

If an exit is fully or partially obstructed, the healthcare organization must post signage that identifies alternative exits by location to everyone affected by the obstruction.

Exit corridors and stairwells are frequently obstructed during renovation activities. Even partial obstructions may make it difficult or impossible to evacuate patients in their beds. Signs explaining the location of alternative exits must be posted in all affected areas, which can be easily accomplished with the assistance of maps or drawings made with a computer-aided drafting program.

On a daily basis, the healthcare organization inspects exits that are affected.

This daily inspection should ensure that exits are still accessible; if they are not, then appropriate measures must be taken. Some healthcare organizations include this daily inspection requirement in the general contractor’s responsibilities, since the standards do not stipulate who must conduct the inspection. However, in my opinion, it is never a good idea to entrust an outside contractor with performing any ALSMs. This person is not an employee of the healthcare organization and may not have the same level of interest in its safety program.

The healthcare organization provides temporary but equivalent operable fire alarm detection systems when a fire alarm system is impaired.

The whole purpose of removing smoke detectors from service during a construction project is to prevent false alarms caused by construction dust or smoke. If the smoke detectors are not required in the first place, then there is no requirement to maintain fire alarm detection during the construction project. However, if the smoke detectors are required, or the healthcare organization wants added detection during the construction project, I have seen cases where the healthcare organization chooses to replace the smoke detectors with heat detectors to provide some measure of protection. The problem is that heat detectors are not equal to smoke detectors, so you cannot rely upon them to serve as a replacement. The only real solution that I have seen is to conduct a fire watch in all areas where the fire alarm or automatic sprinkler systems are impaired. Some healthcare organizations have chosen to use battery-operated smoke alarms that are not tied into the fire alarm system; again, although this can help, it cannot replace the fire alarm system smoke detectors. All temporary systems, including fire watches, must be tested and inspected on a monthly basis.

The healthcare organization provides additional firefighting equipment.

Additional firefighting equipment in a healthcare organization setting means portable fire extinguishers. This is an easy measure to comply with, but it’s not as simple as just setting an extra fire extinguisher in a construction area. First of all, you must select the appropriate extinguisher for the potential fire classification, and the extinguisher must be placed within the travel distance limitations ­appropriate to its class and size. Furthermore, you must mount the extinguisher properly on the wall and or at the appropriate height from the floor.

One may believe that a fire watch is simply walking around the impaired area looking for signs of fire, but there is more to it than that. A fire watch begins by following the healthcare organization’s fire response plan, commonly called RACE:
--- Rescue anyone in harm’s way
--- Activate the alarm and call the emergency number
--- Contain the fire by closing doors
--- Evacuate the area

Individuals conducting the fire watch need to be trained on their duties other than the basic fire response plan. According to National Fire Protection Association (NFPA) standards, a fire watch also needs to ensure that the following items remain true:
1.    Outside doors are closed and secured
2.    All waste and combustible debris is removed from the impaired area
3.    Remaining fire protection equipment is accessible and unobstructed
4.    All corridors are clear of obstructions
5.    All nonessential equipment is shut off
6.    The area must be checked for carelessly discarded smoking material
7.    All unnecessary heat-producing devices are turned off
8.    All flammable gases are stored in a one-hour fire-rated room
9.    All sprinkler control valves are in the open position
10.    The area has proper ventilation
11.    There are no leaks from plumbing fixtures and piping
A form to use as a combination training and notification tool is available in the appendix of this book.

In the Final Rule to adopt the 2012 LSC issued in May 2016, CMS now requires that a fire watch must have a qualified individual in the affected area on a continuous basis, and may not leave until the fire watch has been rescinded, or another qualified individual takes their place. Therefore, if it takes an individual 10 minutes to walk the affected area, then that person must start over right away and walk the area again. If it takes the individual longer than half an hour to walk the affected area, the healthcare organization needs to provide two individuals who can accomplish the fire watch within the required 30 minutes. The people conducting the fire watch must not have any other responsibilities. CMS indicates that it takes this information directly from NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, section A.15.5.2(4)(b), which says:
“A fire watch should consist of trained personnel who continuously patrol the affected area. Ready access to fire extinguishers and the ability to promptly notify the fire department are important items to consider. During the patrol of the area, the person should not only be looking for fire, but making sure the other fire protection features of the building such as egress routes and alarm systems are available and functioning properly.”

Understand the financial implications of a 24-hour/seven-day a week fire watch for a construction project. In order to cover three shifts/day, for seven days, you will need to have five full-time employees (FTE) do nothing but the fire watch. That equates to about $3,500/week, including benefits, or $14,000/month. If the project takes six months to complete, we’re talking over $84,000 just for the fire watch. You can install temporary sprinkler systems in the construction area for a lot less than $84,000.  

Whether the AOs like this more restrictive approach to fire watches, or not, does not matter to CMS. If the AOs are representing CMS, then they are required to meet their requirements. So you can expect all of the AOs to enforce this level of fire watches at all healthcare organizations. 

The healthcare organization provides temporary construction barriers that are smoke-tight or made of non-combustible or limited-combustible materials that would not contribute to the spread of a fire.

With the adoption of the 2012 LSC, the 2009 edition of NFPA 241 Standard for Safeguarding Construction, Alteration, and Demolition Operations is now referenced. Section 8.6.2 of NFPA 241-2009 says temporary walls used to separate construction, demolition and renovation areas from occupied areas must be 1-hour fire resistance rated, with ¾-hour fire rated door assemblies that self-close and positively latch. These walls will have to extend from the floor to the deck above, which may be a challenge for those areas that have a lot of HVAC duct, pipes, and conduit. But section 8.6.2 also says if the construction area is protected with an automatic sprinkler system, then the temporary construction walls and openings may be non-fire rated.

NFPA 241 is very clear as to what qualifies as temporary walls. It says construction tarps are not to be used as the non-construction walls for a sprinklered construction area. Unfortunately for most healthcare facilities, this means flame-retardant plastic sheeting material would not be acceptable as a temporary construction wall. You can still use the flame-retardant plastic sheeting as an Infection Control barrier, but you cannot count on it to serve as the construction barrier. You will still have to install substantial walls, such as steel studs and gypsum board on one side.  

So, if you have a renovation project that removes the suspended ceiling tiles and grid and exposes the sprinklers in place, here are two valid reasons to turn those sprinklers up and install upright heads within 12 inches of the deck: 1) You will not have to conduct a fire watch in the construction area which will save money, and 2) You will not have to install a 1-hour fire resistance rated temporary separation barrier.

The healthcare organization increases surveillance of construction areas, areas used for staging of construction materials, excavation areas, and field offices.

Along with the daily inspections of exits, inspections of construction areas need to be conducted, including material storage areas and field offices. While there is not a prescriptive frequency identified for these inspections, it is generally understood to be a daily requirement. Again, it is my opinion this compensating measure should not be assigned to a nonemployee of the healthcare organization, such as a ­construction company foreman. The responsibility for interim safety is significant and should not be delegated to an individual who may not have the healthcare organization’s best interests at heart.

The healthcare organization enforces the practice of removing construction debris, storage, and basic housekeeping duties to reduce the combustible load inside the building as much as possible.

The nature of a construction project involves installing new materials, which frequently arrive on the job site in some sort of packaging. An organized method to safely store the materials until they are needed should be one of the focuses of the daily surveillance inspections. Once the material is unpacked, the packaging (often combustible materials such as cardboard boxes, wood pallets, and polystyrene) is left to accumulate until it is removed from the site. Proper removal of this packaging or debris from the building should be a daily requirement and another focus of surveillance inspections.

The healthcare organization provides additional training on the use of firefighting equipment for those who would be expected to use it.

During a construction project—or any situation in which the normal fire suppression system is impaired—it may seem logical to provide additional fire extinguishers. However, just providing the extinguishers is not all that’s required; it is also important to make sure the individuals who would be expected to actually use the extinguishers know how to do so.

The healthcare organization conducts an additional fire drill per shift per quarter in all areas
affected by the deficiency.

When is it necessary to conduct an additional fire drill? The answer to that question is one of the least understood issues of all the compensating elements for ALSMs. We must first understand why fire drills are conducted in the first place. The LSC says fire drills are required to familiarize facility ­personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. So, fire drills are required for training purposes to ensure your staff is familiar with the fire alarm signals and know what action is required. Since ALSMs address life safety deficiencies, the purpose of an ALSM fire drill is to ensure that your staff knows what special procedures to follow to compensate for a given deficiency. For example, a fire drill performed in response to an obstructed or closed exit or corridor would assist in training staff on where the alternative exits are located and provide an opportunity for them to demonstrate their knowledge. An ALSM fire drill may also be conducted when a serious breach in a fire or smoke barrier requires staff to evacuate in a different direction until the breach is repaired. Keep in mind, an extra fire drill is required in all areas that are affected by the life safety deficiency. So, if you have an exit that is obstructed, an extra drill must be conducted in each department or unit that utilizes that exit. The extra fire drill must be conducted on all shifts once per quarter—so theoretically, if a main exit were obstructed, there might be many extra ALSM fire drills that would need to be conducted before the main exit is restored.

On a monthly basis, the healthcare organization tests and inspects temporary systems. Any temporary systems used for ALSM purposes, including fire watches, must be tested and/or inspected on a monthly basis. A fire watch inspection could simply consist of auditing the fire watch log sheet to ensure it is being conducted.

The healthcare organization provides additional education to building occupants that promotes awareness of the life safety deficiencies, construction hazards, and any temporary or alternative measures that have been implemented to maintain fire safety.

Promoting awareness can be accomplished in many ways: an email, a memo, verbal instructions, an article in the healthcare organization newsletter, or a posting on the healthcare organization intranet. Whatever the medium, the purpose of this message is to educate the staff on a particular deficiency or construction hazard, such as a particular exit being closed during a renovation project.

The healthcare organization conducts training for building occupants who are affected by the
life safety deficiencies.

This element addresses the need to conduct in-depth training on specific deficiencies that directly affect occupants of the building. For example, if a fire damper has malfunctioned, the staff in that area must know that the fire barrier where the damper is located may not perform as expected.

In summary, the ALSM policy requires every life safety deficiency that cannot be resolved immediately (i.e., on the same day it’s discovered) to be assessed for possible implementation of compensating measures. The healthcare organization decides, in accordance with its ALSM policy, which measure is implemented. It is important to accurately assess each life safety deficiency against all of the measures for potential implementation, as the AO surveyor may review and judge every decision you make.




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